The National Institute for Occupational Safety and Health
(NIOSH) Division of Safety Research (DSR) is currently conducting the Fatal Accident
Circumstances and Epidemiology (FACE) Study. By scientifically collecting data from a
sample of similar fatal incidents, this study will identify and rank factors which
increase the risk of fatal injury for selected employees.

On August 16, 1982, a 29-year-old male foreman fell from
the platform of a 16' welded tubular scaffold and landed head first on the 6"
concrete slab. The foreman died approximately 24 hours later in the intensive care unit of
a local hospital. The attending medical examiner notified DSR on August 20, 1982.

CONTACTS/ACTIVITIES

Subsequent to receiving notification, DSR sent a research
team, consisting of an epidemiologist, safety researcher, civil engineer, safety engineer
and safety specialist, to visit the company on August 26, 1982 and the incident site on
August 26 and 31, 1982. Interviews were held with the co-owner of the company, new
construction foreman and co-workers. Information obtained from these interviews pertained
to company history and processes, policies and procedures, incident scenario, safety and
training programs, employee evaluations, injury records, and relevant work practices. The
incident site was surveyed in the presence of the witnesses who were able to describe the
appearance of the site at the time of the incident. The scaffold and truss involved in the
incident were still at the site and were observed. During the survey, the locations of the
victim, scaffold and truss were identified and 35mm pictures were taken.

SYNOPSIS OF EVENTS

This construction company had been established for
approximately 12 years and had erected numerous commercial metal buildings. According to
the co-owner, the company had no prior history of occupational fatalities nor disabling
injuries.

The construction activity consisted of the erection of a
commercial metal building designed to be a retail tire store. The design consisted of 35
metal trusses (each of which was approximately 60' long, 11' high at the apex, and 300
lbs. in weight) set 40" apart and attached to 18' sidewalls (masonry block and metal
columns) built upon a 6" concrete slab. The building was approximately 60' wide and
110' long with two garage doors on each side with showroom windows and a main entrance
door at the front.

At the time of the incident, the slab with the block and
metal sidewall framing (without exterior panels) were complete and (31 of 35) of the 35
trusses had been set and secured in place. The erected trusses had been raised with either
a hydraulic, telescoping boom crane or a backhoe with extension attachment. Wooden spacers
constructed from 2 x 4's were used to align the truss at a proper distance from a
previously placed truss and to minimize its lateral movement until secured. The trusses
were secured to the sidewalls by two metal screws at each end and to the proximal trusses
by two metal roof purlings which would be attached to the truss by screws.

The working foreman (the victim) and three other employees
were involved in the activity of raising, setting and securing the metal trusses on the
afternoon of August 16, 1982. There were four trusses left to be installed, and the
workers hoped to finish those that afternoon. The victim and another employee were on the
16' scaffold's 8' x 4' platform which did not have guardrails. The other employee was
using a 6' wooden stepladder to reach and remove the hoist chain attached to the truss
which had just been raised into place and aligned with a wooden spacer. In the process of
removing the chain, the truss began to rotate on its base, in a downward direction. The
foreman and other employee grabbed the truss in an attempt to prevent its movement and
subsequent damage. The foreman and other employee were not able to maintain the truss. The
other employee had to let go while the victim continued to hold on. The truss then
continued to rotate on its ends downward and knocked over the scaffold and ladder. It is
not clear whether the victim fell before or after the truss hit the scaffold. The other
employee was able to hold onto a previously secured truss and this prevented him from
falling.

A resident of a nearby home was a trained EMT and was able
to provide quick emergency care for the victim. This care consisted of fitting the victim
with a cervical collar and keeping him warm. An ambulance arrived approximately 40 minutes
after the incident occurred and transported the victim to a nearby hospital.

MEDICAL FINDINGS

While in the hospital, neurosurgery was attempted to
relieve cerebral pressure caused by a massive subdural hematoma. The damage was
irreversible and the victim died approximately 24 hours after being admitted. Toxicologic
tests of blood for alcohol and urine for basic neutral and narcotic drugs were all
negative.

GENERAL CONCLUSIONS AND RECOMMENDATIONS

Several factors contributed to this fatal incident. The
truss' involved in the incident apparently began to move due to the slippage or shearing
of the wood spacer. Spacers observed at the incident site were open-ended and cracked.
These conditions diminish their ability to adequately hold an unsecured truss. When the
truss began to fall, the victim not only grabbed it but also apparently refused to let go
in apparent disregard for his own safety. Also, although less contributory since the
entire scaffold was knocked over, the victim and other employees were working from a
platform which had no guardrails.

It is recommended that future efforts be made to utilize a
more suitable type of temporary spacer. A spacer made of metal and with clasps to fasten
it in place would be less likely to be dislodged. Safety training should stress that
workers should not grab onto large objects in motion. Future efforts should stress the
importance of and strictly enforce the proper use of guard rails around scaffold
platforms.

The courtesy and cooperation of the company officials and
employees are gratefully acknowledged.